Parkinson's patient

Q: I just evaluated a 69-year-old VERY brilliant woman with Parkinson's Disease. As a research person, she is SO very interested in IM. She is right-handed, has decreased right shoulder ROM, decreased balance (with numerous falls). She had a brain stimulator placed May 2005. She is at our facility seeking additional voice therapy, but wanting to primarily focus on cognition (attention, impulsivity, rate of processing). Would you use IM with her from a cognitive perspective? If so, please provide some specifics. If not much has been done with Parkinson's and IM, she indicated she would love to try it, unless it is totally contraindicated.

A: IM is being used successfully with Parkinson's patients for both the motor and cognitive symptoms. I would suggest following the six phases of IM treatment, beginning with easier hand tasks. Try having her do all tasks seated in a chair initially for maximum focus. See if she does best with the auditory mode alone versus use of the visual mode.  If she wears hearing aids, then you will need to use speakers. If using speakers, be sure they are positioned so that one is on her left and the other on her right and are placed at the level of her chest or head. 

Go with what she does best to bring along her cognitive skills and get him really good at the IM using the easiest hand tasks before proceeding to lower extremity tasks. Keep tasks short initially and repeat the same task over and over in the same session. If her processing speed is slow or she exhibits motor initiation/motor planning/sequencing deficit (which she likely will with Parkinson's) and you find that she struggles to match the beat or to process the guide sounds, then try making the following adjustments:

A.  Turn down the tempo a bit - try 45 or 50.

B.  Adjust the volume of the guide sounds so that the reference tone is loudest and the guide sound volumes are lower - this makes it easier to attend to the reference tone.

C.  Adjust the Difficulty to an easier setting, like 300, so that he does not hear the very early/very late buzzer too often, which can be discouraging and distracting.

Since Parkinson's is a progressive disease, she will not maintain gains from IM treatment. Realizing this and that there is a need for flexibility with the provision of IM treatment,  IM now offers a take home product called IM-HOME. Clinicians that are using IM successfully with Parkinson's patients are transitioning them to the IM-HOME upon completion of their IM treatment in the clinic setting. The IM-HOME allows for the patient to upload their IM data and send it via email to the clinician for monitoring of their program.  If you notice a decline, you can contact the patient to have her come in for reassessment. IM-HOME is not covered by insurance, but the cost is reasonable, especially considering that it will help the patient maintain maximum level of motor and cognitive function possible for a greater period of time. 

This IM-HOME is also useful for those patients who have limited insurance benefits or cannot get the clinic often enough for an appropriate treatment intensity for scheduling reasons or location. They can continue their IM treatment at home or supplement the IM treatment in the clinic with a home program. 
 

Cancer patient

Q: I am working with a 47-year-old male, s/p nasal cancer resection which resulted in numerous complications including a CVA with left-sided involvement. Considerable visual involvement, rate of processing challenges and impulsivity. IM was utilized, and wife has said all impulsivity has ceased. Other good comments as well. I am wanting to utilize some bilateral IM, but his left hand and foot are simply not real cooperative. Would you skip the bilateral component, but isn't bilateral better when one side of brain is so involved?

A: Isn't IM amazing?!  I would begin bilateral tasks in this manner:

Set up a task whereby the patient must use his intact upper extremity to alternate between tapping a target on the same side then on the contralateral side.  I would then use the impaired upper extremity and do the same task, providing as much assist as he needs to do it.  Repetition is key. Have him perform the task for as many repetitions as tolerated. Reduce the tempo and turn off the guide sounds when using the impaired extremity. You may need to reduce the tempo all the way to 30 if he is really impaired. 

You can incorporate visual scanning and functional reach with such tasks by placement of the target and by the visual stimuli you use. For example, the patient can cross midline to tap a sequence of targets, perhaps cardstock cutouts that are labeled with numbers (using a Sharpie pen). He can tap on a number each beat1-2-3-4-5. You can make the task easier or more challenging depending upon placement of the stimuli (distance he must reach, involve more crossing of midline, add more numbers). Get creative. Do alphabet letters. Do colored squares...have him tap on a color sequence red - green - yellow - blue.  When it comes to bilateral tasks, there are ways to accomplish it without doing the standard IM tasks of Right Hand/Left Toe or Left Hand/Right Toe.  Performing such tasks will tap into a whole range of visual processing skills in addition to executive functions such as anticipation and sequencing.

To address the visual involvement:  Using his best task, pair several tasks in the following sequence:

A.  Set task duration according to patient's tolerance - try to go for longer task duration so that he benefits from a lot of repetition.

B.  Reduce tempo to anywhere between 40-50 (due to slow processing) and make him perform IM with visual mode on (Shape with Center Flash or Score with Center Flash).  You will need to trial various tempos to see what works best for his processing speed.

C.  Have him perform IM with the auditory and visual modalities combined until he gets good at the IM (ms averages in normal range for his age group).  This may take several sessions.

D.  Once "C" is completed, begin to reduce the master volume on the IM so that it is set at 3 - repeat same task with auditory and visual IM.  Stay here until he is performing in normal range. 

E.  Reduce master volume to 0 - repeat same task again with auditory and visual IM. Stay here until he is performing in normal range.

F.  Turn off all IM sound - no headphones or speakers used - have him perform IM with just the visual mode.  It is essential that you use the visual mode with the center flash for this.

He may plateau out at some point and never reach "F." 
 

Tumor resection patient: 

Q: A 56-year-old right-handed female, s/p left brain tumor resection, with resulting visual processing challenges, attentional concerns, math problems, etc. In general, pt very high level and is planning a return to pre-morbid employment. Pt has made remarkable gains with "scanning" and IM. I have also utilized some divided attentional tasks with IM. Any suggestions? Again, any input with the bilateral component? Any specific protocol recommendations for choosing right hand vs left toe vs. left hand vs. right toe?

A: I would do similar tasks to that described above (cancer).  I also like variations of patty cake that involve sequencing and crossing midline.  Begin without the IM on, go as slow as the patient needs.  Then turn the IM on at a slower tempo (40) without the guide sounds - don't worry about the patient wearing a hand trigger.  Gradually, the patient should wear the hand trigger and hear the reference tone alone.  As the patient performs well with the reference tone alone, turn on the guide sounds with the difficulty set at 300.  Gradually adjust the difficulty back to 100.  Pair short tasks in the same session so that on each successive task, the tempo is raised slightly.  Notch the tempo up higher and higher as tolerated to as high as 65-80 beats per minute.  Begin with a 4 step patty cake sequence and progress to 5 then 6 then 7 steps and more as tolerated. Incorporate use of the feet at some point in the sequence. Try doing IM with the radio on at the same time. Once the patient gets good at patty cake with IM settings at maximum challenge, incorporate other tasks of divided attention (i.e., while patient is sequencing through patty cake, read a story to the patient then require the patient to answer questions about the story upon completion of the task).